Peds Module

7M O D U L E 7

Delivery and Immediate Neonatal Care

William Keenan | Enrique Udaeta | Mariana Lpez | Susan Niermeyer

INtrODUCtION

Approximately 1 million neonatal deaths occur each year due to perinatal asphyxia. It is one of the leading causes of perinatal and neonatal mortality and is associated with a very high incidence of irreversible neurologic damage. Prompt and skilled resuscitation can prevent many of these deaths and reduce disability in survivors. Under ordinary circumstances, about 1 in 10 newly born infants will require some resuscitation intervention. This proportion is higher during periods of social and environmental stress.

The ABC principles of resuscitation are the same for all age groups. The airway must be open, breathing must be adequate, whether spontaneous or assisted, and circulation of oxygenated blood must take place.

Neonatal jaundice is also extremely common and since it can be associated with serious pathologies, this module will address the management of this complication.

Delivery and Immediate Neonatal Care

William Keenan, MD, FAAPEnrique Udaeta, MDMariana Lpez, MD

Susan Niermeyer, MD, FAAP

7

SECtION I / DelIvery AND ImmeDIATe NeoNATAl CAre

DELIvEry aND IMMEDIatE NEONataL CarE

ObjECtIvES

l list the elements needed to successfully carry out neonatal resuscitation, including recognition of risk factors associated with the need for neonatal resuscitation and preparation of the environment, personnel, and the equipment necessary for neonatal resuscitation.

l Identify the newborn who is making a normal transition immediately after birth.

l recognize the newborn who requires resuscitation.

l Describe and apply effective neonatal resuscitation interventions.

CaSE.you are delivering health care at a shelter for people displaced following an earthquake. A 15-year-old comes to the health care post. She is in labor and had spontaneous rupture of membranes 2 hours earlier. The amniotic fluid is clear. She has had only one prenatal checkup, at 5 months of pregnancy. According to the date of her last period, she is in the 39th week of gestation. Immediate assessment reveals that she is currently hypertensive, and fetal bradycardia is detected through auscultation.

l Which are the risk factors in this patient?l Which elements are crucial to ensure adequate neonatal care?

anticipation, preparation, recognition, and interventionA successful resuscitation relies on anticipation based on prenatal and

intrapartum risk factors, preparation for all deliveries, recognition of the need for resuscitation, and adequately skilled intervention.make an obstetrical assessment for

any pregnant woman who has a fever or other illness, or who is in labor or prema-ture rupture of membranes (Prom) before the onset of labor. refer to a maternal and child health service whenever feasible and appropriate. Give all human immu-nodeficiency virus (HIv)-positive preg-nant women antiretroviral medications as indicated.

anticipatory planningevery disaster situation is likely to involve pregnant women and their newborns. Because more than 10% of newly born infants will require resus-

Make an obstetricalassessment for anypregnant woman whohas a fever or otherillness, or who is inlabor or with pre-labor rupture ofmembranes (PROM).

Every disaster situa-tion is likely to involvepregnant women andtheir newborns.

4 SECtION I / DelIvery AND ImmeDIATe NeoNATAl CAre

citation, anticipatory planning will be fundamental for these interventions to be successful.

What personnel should be available?If possible, notify personnel with skills in neonatal resuscitation. At least one person who is capable of initiating resuscitation should be present at each birth and immediately available to the newborn. others who might function as part of a resuscitation team should be available as the need arises. It is important to prepare the area in which the delivery will occur, check the equipment and review the functions of personnel immediately prior to the delivery. Personnel should review the emergency plan for communication and transportation if either mother or infant needs an advanced level of care.

What maternal, fetal, and neonatal conditions might indicate a higher risk of neonatal depression?The need for resuscitation cannot always be predicted; it must be kept in mind that prompt neonatal resuscita-tion might be necessary after any birth. However, some perinatal conditions associated with a need for resuscita-tion can be recognized in advance. Some of those conditions are shown in box 1. Thorough assessment of the risk factors allows for the identifica-tion of more than half of the deliveries that will need neonatal resuscitation. Prospective identification of perina-tal high-risk factors should prompt

bOX 1. risk factors associated with probable need for neonatal

resuscitation

before deliveryl maternal diabetesl maternal hypertensionl Anemia or isoimmunizationl Previous fetal/neonatal deathl Post-term gestationl multiple gestationl Polyhydramnios or oligohydramnios

l Premature (pre-labor) rupture of membranes (Prom)

l maternal infectionl maternal consumption of drugs or medications

l Any other maternal illnessl Diminished fetal activityl Known fetal malformationsl lack of prenatal carel maternal age 35 years old

During deliveryl labor at less than 8 completed months of pregnancy

l rapid laborl emergency cesarean section or use of forceps

l Prolonged Proml Fetal distress (alterations in the fetal heart rate)

l Significant vaginal bleedingl Placental abruptionl Prolonged labor according to evaluation by partogram

l meconium-stained amniotic fluid

l Umbilical cord prolapse and tight nuchal cord

l Anticipated low birth weightl Anticipated high birth weight

5SECtION I / DelIvery AND ImmeDIATe NeoNATAl CAre

the transfer of the pregnant woman or the mother and her newly born infant to facilities with enhanced care resources. Keep the mother and baby together, especially if transfer is nec-essary. The Integrated management of Childhood Illness (ImCI) strate-gy from the Pan American Health organization (PAHo) and the World Health organization (WHo) includes the assessment and classification of pregnancies in order to determine the risk level and adequate treatment (table 1). Identification of high-risk factors can also facilitate communica-tion with the family and timely mobili-zation of the resuscitation and mater-nal health care team.

What equipment should be available?It is recommended that sterile delivery kits be available. An example of the contents of a delivery kit is provided in box 2.A neonatal-sized resuscitation bag or

other device capable of giving con-trolled positive pressure with appro-priately sized face masks should also be available. The use of endotracheal tubes, laryngoscopes, intravenous administra-tion sets, and medications is dictated by availability of supplies and personnel skilled in their use. For further details consult a more advanced source, such as the sixth edition of Textbook of Neonatal Resuscitation from the American Academy of Pediatrics (AAP) and the American Heart Association (AHA).

What are the appropriate delivery procedures?It is essential to utilize appropriate personal protection; personnel should use sterile gloves to the extent possible.Clamp or securely tie the umbilical

cord with sterile string about 2 and 5 finger breadths from the abdomen. Cut the cord between the occluded sites with a sterile blade or scissors; avoid contamination. A short delay of 1 to 3 minutes between birth and cord ligature or clamping benefits vigorous infants. Some recommend that, if time allows, the cord be clamped only after visible pulsation has stopped.remember to perform adequate

identification procedures for the new-born (take the infants footprints in a form together with the mothers fingerprint and provide the newborn with an identification bracelet, if avail-

bOX 2. Sample delivery kit

before deliveryl Cord clamps or ties (at least 2)

l razor blade or sharp scissorsl material for hand hygieneeither an alcohol-based hand-cleaning solution or a bar of soap and clean water

l Clean cloths (at least 2) to be used for drying and wrapping the infant


tabLE 1. Classification to assess and determine pregnancy risk

(rED)one of the following signs: labor at 41 w reduced or absent fetal movements Severe systemic disease Infection with fever (UTI, bacterial or viral sepsis, chorioamnionitis, malaria)

Uncontrolled diabetes vaginal bleeding Pre-labor rupture of membranes (Prom) >12 h Uncontrolled hypertension and/or seizures, blurred vision, loss of consciousness or intense headache

Changes in fetal cardiac frequency (FCF) Intense palm pallor and/or Hb


able). This issue takes on added impor-tance in situations of administrative disorder, as is usually the case in acute humanitarian emergencies.Provide the child with an environ-

ment as warm as possible. It is essential to dry the infant immediately. leaving the baby wet may result in cold stress. early skin-to-skin contact with the mother has been shown to be effective and desirable. Immediate breastfeed-ing following delivery is advisable for healthy infants. even if the newborn requires resuscitation and ongoing care, present him to the mother at least briefly.

recognition Three major questions should be asked about every newly born child to define the need for resuscitation:l Is this a full-term gestation? For a variety of reasons, a preterm baby is much more likely to require interventions. moreover, in case resuscitation is needed, preterm newborns anatom-ic and physiologic characteristics are different from those in term new-borns, and these differences should be taken into consideration: pulmo-nary surfactant is often insufficient, which leads to difficult ventilation; skin is thinner and permeable; skin area is larger and there is less sub-cutaneous tissue, which increases heat dissipation; more vulnerability to infection; more fragile cerebral capillaries, with increased probability of CNS hemorrhage under situa-tions of stress.

l Is the baby breathing or crying? Absent respiratory effort (apnea) or inad-equate respiratory effort (gasping; breathing with superficial and inef-fective inspiratory movements) is the first reason to initiate resuscitation.

l Is there good muscle tone? Poor mus-cle tone might indicate hypoxemia. Preterm newborns normally have a lower muscle tone than term babies. Term infants with good respiratory

effort and muscle tone can be dried and placed over the mothers body for better thermal protection and suckling under continued observation.

resuscitation treatmentThe sequence of neonatal resuscitation for the baby with identified risks (pre-term, poor or no respiratory effort, or poor muscle tone) begins with thermal protection, proper positioning of the newborn, and brief stimulation. Attending personnel should observe hand hygiene and protect the baby from contamination at all times.l Thermal protection. Dry the baby rap-idly to reduce evaporation. A radiant heater can be used if available. If a warming device is used, hyperther-mia must be avoided. If resuscitation interventions are required, wrapping a very preterm infant in clear food-grade plastic film is effective in reduc-ing cold stress while allowing access to the infant. Cover the babys head with a cap. A sick baby who needs to be transported can be protected from cold by placing an exothermic chemical mattress under a blanket,

Three major questions should be asked about every newborn child to define the need for resuscitation: Is this a full-term gestation?

Is the baby breathing or crying?

Is there good muscle tone?


skin-to-skin contact with an adult, or swaddling in warm blankets covered by a windproof, reflective outer layer. Heating pads, hot water bottles, and surgical gloves filled with hot water should be avoided because they can cause extensive burns.

l Position. The airway of the hypotonic baby is vulnerable to obstruction with flexion or extension of the neck. Position the infant on the back or side, with the head slightly extended in the sniffing position (Figure 1). A small roll of cloth placed under the shoulders may be helpful in maintaining head position.

l Airway clearing. remove secretions that obstruct the airway by wiping the nose and mouth with a cloth or by using a suction device. Suction the mouth before the nose (Figure 2). Suction must be gentle and not very deep. roughly suctioning or touch-

ing the posterior wall of the pharynx with the suctioning device may cause apnea and bradycardia through vagal stimulation. The presence of meconi-um in the amniotic fluid can be a sign of fetal distress. Pharyngeal suction-ing during birth has not been dem-onstrated to reduce the incidence of meconium aspiration syndrome. When the baby is meconium-stained and not immediately vigorous (vigor-ous = strong cry, good muscle tone, and heart rate above 100 beats/min), tracheal suctioning should be considered. Personnel skilled in neo-natal tracheal intubation and proper equipment would be required for this step.

l Stimulation. Drying an infant thor-oughly generally provides sufficient stimulation of breathing in a healthy newborn. Additional stimulationflicking the soles of the feet or

FIGUrE 1. Correct and incorrect head positions for resuscitation

Correct

Incorrect (hyperextension)

Incorrect (flexion)

Adapted from Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 6th ed. AAP/AHA; 2011.


rubbing the back, for examplemay encourage the initial respira-tory effort and continued breathing during the early transitional period if needed. vigorous or prolonged stimulation may cause great harm to the baby and is not part of skill-ful resuscitation. table 2 lists some inadequate stimulation procedures and the harmful consequences that may ensue.

If supplemental oxygen is available, when is it indicated?A number of studies have demon-strated that for most neonatal resus-citations requiring positive-pressure ventilation, room air is as effective as 100% oxygen. Data also indicate that in the first several minutes after birth cyanosis is common in babies who have normal outcomes. The AAP Neonatal resuscitation

Program 2011 update includes the fol-lowing recommendations for oxygen supply during resuscitation:

Adapted from Integrated Management of Childhood Illness (IMCI). PAHO/WHO. Washington, DC; 2004.

tabLE 2. Inadequate stimulation procedures

Procedure Consequence

Clapping on the back Contusions

Squeezing the chest wall

Fractures, pneumothorax, severe difficult breathing, death

Pressing the lower extremities over the abdomen

liver or spleen rupture

Anal sphincter dilation

Sphincter lesion

Cold or hot compresses or bathing

Hyperthermia, hypothermia, burns

Shaking Hemorrhages or brain damage


FIGUrE 2. Suctioning the mouth and nose; m [mouth] before N [nose]

Mouth first

then nose


room air to initiate positive- pressure ventilation in term infants and avail-ability of moderate oxygen concen-trations for initiation of PPv in very preterm infants. oximetry when

l resuscitation can be anticipatedl Positive pressure is administered for more than a few breaths

l Cyanosis is persistentl Supplementary oxygen is administered

Targets for oxygen saturation cor-respond to preductal saturations of healthy term babies in the first minutes after vaginal birth at sea level. These initial steps and possible sub-

sequent actions are outlined in the flow diagram shown in Figure 3. Further steps in resuscitation are dis-cussed in the following paragraphs.

FIGURE 3. Flow diagram for neonatal resuscitation

Post-resuscitation care

Skin-to-skinBreastfeeding

BIRTH

Approximate time

Term gestation?Breathing or crying?Good muscle tone?

HR 100

30 sec

30 sec

30 sec

30 sec

Provide warmthDry, position, clear airway (as necessary)

Stimulate

Evaluate respirations

Not breathing

Provide positive-pressure ventilation

Provide positive-pressure ventilationTake steps to improve ventilation (if

advanced care available)

Administer chest compressionsConsider endotracheal intubation and

medication* (if available and appropriate)

*Epinephrine IV 0.01.03 mg/kg. Adapted from Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 6th ed. AAP/AHA; 2011.


additional neonatal resuscitation procedures Evaluation for further resuscitation interventionsAt the completion of the initial steps (thermal protection, positioning, clear-ing of the airway, and stimulation), respirations and heart rate.

respiration There should be adequate respiration as judged by chest movements and respiratory rate.

ventilationPoor respiratory effort, as manifested by apnea or gasping (deep, intermittent, slow, spasmodic inspiratory efforts), is the major indication to initiate neo-natal resuscitation, and ventilation is the key to successful resuscitation. If the newborn does not rapidly estab-lish effective spontaneous respiration, positive-pressure ventilation must be administered immediately.

What are the elements of positive-pressure ventilation?The goal of positive-pressure venti-lation is to inflate the lungs with an adequate breath. Inspirations that are too small will be ineffective for those in most need, and inspirations that are too large can damage the lungs. The effectiveness of ventilation can be judged as outlined in box 3.many kinds of devices deliver

positive-pressure ventilation for neo-natal resuscitation. Flow-inflating bags,

self-inflating bags, T-piece devices, one-way valve masks, and laryngeal masks are some of these devices. most critical is the skill of the person who is oper-ating any of these devices. Potential resuscitators should review the opera-tion of the available devices, practice mock resuscitations, and test the oper-ation of all bags, valves, connections, and safety features. Figure 4 illustrates the use of a self-inflating bag with a mask. The head is slightly extended. The mask covers the mouth and the nose. The fingers of the left hand lift the chin forward and upward and partially encircle the mask, placing light and even pressure downward onto the face to help create an adequate seal. The best indication of adequate lung inflation is the improvement in heart rate, color, and muscle tone.

How is positive pressure delivered?A good seal with the mask and good positioning are essential. The rec-ommended respiratory rate is 40 to

BOX 3. Signs of effectivepositive pressure ventilation

Patient responds- Rapid improvement inheart rate- Improvement in skin colorand muscle tone

Breath sounds heard byauscultation over the chest

Slight rise and fall in thechest

If the patient is notimproving, the mostfrequent cause is poordelivery of positivepressure.

FIGURE 4. Light pressure on the mask when lifting upward on the chin will help create a seal. Anterior pressure on the posterior rim of the mandible (not shown) may also help open the airway.


Poor respiratoryeffort, as manifestedby apnea or gasping(deep, intermittent,slow, spasmodicinspiratory efforts) isthe major indicationto initiate neonatalresuscitation.

The goal of positivepressure ventilation isto inflate the lungswith an adequatebreath.

The goal of positive-pressure ventilation is to inflate the lungs with an adequate breath.


60 breaths per minute as illustrated in Figure 5.

What if bag and mask ventilation is not effective?If the patient is not improving, the most frequent cause is poor delivery of positive pressure. Failure to administer adequate positive pressure may be due to one of three common problems:l An inadequate seal of the mask to the face:- reapply the mask to the face and lift the jaw up towards the mask.

l A blocked airway:- reposition the head to regain slight extension.

- Then check for secretions in the nose and the mouth.

- Then slightly open the mouth and continue positive-pressure ventilation.

BOX 3. Signs of effectivepositive pressure ventilation

Patient responds- Rapid improvement inheart rate- Improvement in skin colorand muscle tone

Breath sounds heard byauscultation over the chest

Slight rise and fall in thechest

If the patient is notimproving, the mostfrequent cause is poordelivery of positivepressure.

FIGURE 4. Light pressure on the mask when lifting upward on the chin will help create a seal. Anterior pressure on the posterior rim of the mandible (not shown) may also help open the airway.


FIGURE 5.Counting out loud to maintain a rate of 40 to 60 breaths perminute

Two........ Three.......(release)

Two.......Three......(release)

Breathe.......... (squeeze)

Breathe........(squeeze)

FIGURE 6.Compression (top)and release (bottom) phases ofchest compressions



l Need for larger breath:- Increase the inflation pressure to achieve a slight rise and fall in the chest with each breath

What if the requirement for bag and mask ventilation is prolonged?The inflations might distend the stom-ach and interfere with ventilation. In this case, insert a small plastic or rub-ber catheter through the mouth, aspi-rate the stomach contents, and fix the open end of the tube to allow continu-ous drainage.Ask an assistant to check the heart

rate during positive-pressure ventila-tion or pause ventilation after 1 min-ute to check the heart rate if you are alone. The normal heart rate is greater than 100 beats per minute. The pulse at this time can be felt easiest at the base of the umbilical cord or can be heard with a stethoscope over the left side of the chest.

Chest compressionsWhen should chest compressions be initiated?Chest compressions are added to positive-pressure ventilation if the heart rate stays below 60 beats per minute after 1 minute of positive- pressure ventilation.

How should chest compressions be performed? encircle the chest with both hands, thumbs on the lower third of the sternum, and quickly compress to one

third of the chest depth to generate a palpable pulse.Note that ventilation should be con-

tinued and coordinated with the com-pressions. The thumbs are never lifted off the chest during the compression cycles (Figure 6).

How is positive-pressure ventilation coordinated with chest compressions? In order to adequately perform both resuscitation procedures, have a sec-ond person available to give cardiac compressions. Coordinate the pro-cedures to perform 1 breath every 3 compressions, and count aloud fol-lowing a rhythm of: one and two and three and breathe, one and two and three and breathe. The recom-mended rate is to deliver 90 compres-sions and 30 ventilations per minute.The baby should attain a pink color

in the trunk and mucous membranes. If cyanosis persists in these areas, the infant is hypoxemic. Blended oxygen should be administered as guided by pulse oximetry.

Other common questions regarding neonatal resuscitationHow quickly should resuscitation be started?Prompt resuscitation is the most effec-tive. If the infant is apneic, gasping, or breathing ineffectively after dry-ing, clearing the airway, and providing additional stimulation, begin positive-pressure ventilation. Usually the new-


born will be less than 1 minute old (Figure 3).

How quickly should cardiac compressions be initiated? Initiate cardiac compressions if the heart rate remains

SECtION II / JAUNDICe

jaUNDICE

ObjECtIvESl Assess, classify, and define the

treatment of neonatal jaundice.

jaundiceNeonatal jaundice is extremely com-mon. Physiologic jaundice, the most frequent form of neonatal jaundice, is due to immaturity involving biliru-bin metabolism in the liver combined with certain features in the newborns intestinal function (delayed intestinal transit, enhanced intestinal biliru-bin reabsorption causing overload of the enterohepatic circuit). It may also relate to the newborns feeding. Jaundice associated with breastfeed-ing is another form of usually benign neonatal jaundice that can prolong physiologic jaundice. It is interesting to note that indirect bilirubin (the one that accumulates in physiologic jaundice) is a powerful antioxidant, so during the neonatal period, when the infant is exposed to oxidative stress, moderate levels of bilirubin may be a protective factor.

A variety of hematologic, metabolic, and infectious diseases that require early recognition and treatment can present with hyperbilirubinemia. At the same time, prevention of brain damage caused by very high levels of indirect bilirubin demands early recog-nition and prompt treatment.

assessment of the newborn with jaundiceInformation gathered when assessing an infant with jaundice must include age, gestational age, birth weight, cur-rent weight, onset and duration of the jaundice, characteristics of the stools (quantity and color), and urine color. Newborns with pathologic perinatal history or a family history of another newborn with significant jaundice are at higher risk of developing severe jaun-dice. In addition, jaundice that appears within the first 24 hours after birth or persists for more than 10 days should be assumed to be severe, unless the opposite is proven. (Breastfeeding jaun-dice is a diagnosis made when no other cause has been found.) on physical examination, danger

signs of severity in an infant with jaundice include: poor suck, lethar-

Physiologic jaundice, the most frequent form of neonatal jaundice, is due to immaturity of bilirubin metabolism in the liver combined with certain features in the newborns intestinal function.


Jaundice that appears within the first 24 hours after birth or persists for more than 10 days should be assumed to be severe, unless the opposite is proven.

A variety of hematologic, metabolic and infectious diseases that require early recognition and treatment can present with hyperbilirubinemia.

FIGUrE 7. estimates of bilirubin blood levels according to skin involvement

l How old is the child?l What was his/her birth weight?l Since when is he/she yellow?l Has he/she been passing stools?l What color are the stools?l What color is the urine?l Is there a family history of significant

neonatal jaundice?

l Degree of jaundice1. only in the face2. Up to the navel3. Up to the knees4. Up to the ankles5. Palms/ soles

State of consciousnesslethargic, irritable, normal

assess:- Current weight

Estimate of indirect bilirubin, according to compromised zone

- Zone 1 = 6 mg/dl- Zone 2 = 9-12 mg/dl- Zone 3 = 12-15 mg/dl- Zone 4 = >15 mg/dl- Zone 5 = >18 mg/dl

gy, irritability, poor general condition, seizures, difficult breathing, apnea, whining, cyanosis, intense pallor, and poor capillary refill. Physical exami-nation also allows a rough estimate of bilirubin blood levels according to the extension of jaundice. Jaundice

extends in a cephalocaudal direc-tion with increasing blood levels (Figure 7).Based on the data gathered through

history and physical examination, ImCI classifies jaundice and defines the cor-responding treatment (table 3).

Adapted from Integrated Management of Childhood Illness (IMCI). Model chapter for textbooks. PAHO/WHO. Washington, DC; 2004.

aSK EXaMINE


Signs Classify as treatment

(rED)Jaundice and one of the following characteristics: Any visible jaundice starting before 24 hours after birth

No stool evacuation Jaundice up to ankles or palms and soles (zones 4 and 5)

lethargic or irritable Pathologic perinatal history more than 10 days of jaundice of any degree

(rED)

Severe jaundice

(rED) Continue breastfeeding the infant

refer UrGeNTly to hospital, observing the guidelines for stabilization and transportation

If transportation is needed, counsel the mother to keep the newborn warm during the trip

(yELLOW) Jaundice up to the knees(zone 3)

No signs of severe jaundice

(yELLOW)

moderate jaundice

(yELLOW) Counsel the mother to continue breastfeeding the infant and keep him/her warm

Specify signs of alarm and schedule a control visit in 24 hours

(yELLOW) Jaundice in the face or up to the navel (zones 1 and 2)

No signs of severe jaundice

(yELLOW)

mild jaundice

(yELLOW) Counsel the mother to continue breastfeeding and keep the infant warm

Specify signs of alarm and schedule a control visit in 48 hours

(GrEEN) No jaundice

(GrEEN)

No jaundice

(GrEEN) Counsel the mother to continue breastfeeding the infant

Check vaccination Teach the mother how to care for the infant at home

Specify danger signs Schedule a control visit in the clinics for healthy children

tabLE 3. Classification of jaundice

Adapted from Integrated Management of Childhood Illness (IMCI). Model chapter for textbooks. PAHO/WHO. Washington, DC; 2004.


SUMMaryWhen treating newborns, good hand hygiene must be observed, and

babies must be protected from contamination.If gestation is not full-term, breathing is not vigorous, or muscle tone

is poor, the first step is to ensure thermal protection and dry the infant thoroughly; next, position the head, clear the airway as necessary, and stimulate the breathing child. evaluate breathing. If apnea, gasping, or inad-equate breathing is observed, give positive-pressure ventilation and mobilize additional resuscitation team members. The child is evaluated again after 1 minute of positive-pressure ventilation and steps to improve ventilation (if necessary). If apneic, support is continued. If heart rate is 60 beats per minute on reevaluation, cardiac compressions are discontinued. on further evaluation, if heart rate is >100 beats per minute and spontaneous respira-tions are adequate, positive- pressure ventilation is discontinued.Jaundice can be associated with severe pathologies and can lead to irre-

versible consequences. observe closely patients with jaundice and evaluate them over subsequent hours and days.Communication with and emotional support for the mother is of high pri-

ority. mothers and babies should be kept together, if at all possible. Infants with ongoing problems or high-risk conditions should be referred to a higher level of care as appropriate.

Guidelines on Basic Newborn Resuscitation: Geneva: World Health Organization. In press.

Helping Babies Breathe Web site. http://www.helpingbabies breathe.org

Kattwinkel J, Perlman JM, Azi K, et al. Part 15. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S909S919. DOI: 10.1161/CIRCULATIONAHA.110.971119.

Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 6th ed. American Academy of Pediatrics and American Heart Association; 2011.

Tan A, Schulze A, ODonnell CP, Davis PG. Air versus oxygen for resuscitation of infants at birth. Cochrane Database System Review 2003;(2):CD002273.

World Health Organization/Panamerican Health Organization. Integrated Management of Childhood Illness. Model chapter for textbooks. Washington, DC; 2004.

World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva: 2003.

SUGGEStED rEaDING


Case resolutionIn this case, several risk factors are associated with the need for neonatal resus-citation: patients age, inadequate prenatal care, maternal hypertension, and alterations in fetal cardiac frequency. A newborn exhibiting these risk factors is likely to need advanced resuscitation procedures. Ideally, refer the patient to a high-complexity mother-child care center. If that is not possible, it would be pref-erable to rely upon trained personnel and adequate equipment for an advanced resuscitation. It would be important to transport the child to a neonatal special-ized center immediately after initial resuscitation for further care.


MODULE rEvIEW

SECtION I- DELIvEry aND IMMEDIatE NEONataL CarE

1. What are the key steps for a successful resuscitation? 2. What equipment and supplies are needed to perform neonatal

resuscitation? 3. What maternal, obstetric, and fetal (or neonatal) factors indicate a

high probability of needing advanced neonatal resuscitation? 4. What are the steps in initial resuscitation (reception) of the

newborn? 5. What are the indications for oxygen administration and how should it

be administered? 6. What signs are used to gauge the need for advanced neonatal

resuscitation? 7. When and how should assisted respiration (ventilation) be

administered to the newborn? 8. When and how should chest compressions be performed during

neonatal resuscitation? 9. When and for how long should resuscitation procedures be

performed?10. Under what circumstances is neonatal resuscitation contraindicated?11. What elements are necessary to assess and treat the infant with

neonatal jaundice?

SECtION II- jaUNDICE

1. What signs should be assessed to determine the intensity and severity of jaundice?

2. How is bilirubin blood level estimated according to the extent of cutaneous jaundice?

3. What treatment corresponds to severe, moderate, and mild jaundice?